Utility of substance-free alternatives in treating and preventing harmful substance use: A narrative review of the translational research spectrum.

Interventions primarily focused on constraining access to substances have largely failed to reduce substance use and associated harms. Alternative approaches informed by behavioral theories of choice focus on reducing harmful substance use by increasing access to and engagement in substance-free rewards that can compete with substance use. This narrative review of the translational research spectrum, organized by research phases in the Food and Drug Administration's Drug Approval Process, summarizes wide-ranging research on associations between substance-free alternatives (palatable stimuli, money, social interaction, physical activity) and substance use and related harms. Studies reviewed span laboratory experiments with nonhuman animals to human experiments and treatment and prevention research. With limited exceptions, research across the translational spectrum supported the role of substance-free alternative rewards in reducing harmful substance use. Effective substitutes for substance use under specific conditions included palatable stimuli in animal studies and monetary incentives and social interaction opportunities with non-substance using peers in human studies. Evidence for physical activity was mixed, with stronger support found in animal than human research. Emerging research further suggests that increasing access to substance-free activities in broader socioecological contexts surrounding harmful use (e.g., communities, drug-related policy) also are needed. Increasing access to substance-free rewards through individual- and community-level interventions is a promising alternative to conventional approaches that primarily focus on reducing substance use and related negative consequences by constraining access to substances. Community-level and public health policy efforts guided by behavioral theories of choice merit further development and evaluation.